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Mapping of Vocal Risk in Amateur Choir

Article · April 2016

DOI: 10.1016/j.jvoice.2016.03.002

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Milka Rosa Mara Behlau

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 ARTICLE IN PRESS
Mapping of Vocal Risk in Amateur Choir
Milka Rosa and Mara Behlau, São Paulo, Brazil

Summary: Objectives. The study aimed to investigate and map the existence of vocal risk in amateur singers, ana-
lyzing the contribution of general voice signs and symptoms, specific singing handicap, and generalized anxiety.
Study Design. This is a cross-sectional study.
Methods. The sample comprised 526 volunteer amateur choristers—186 male and 340 female—(mean age of 42.07
years) from different choirs in the region of São Paulo. Three questionnaires were used: the Voice Symptom Scale (VoiSS),
the Modern Singing Handicap Index (MSHI), and the Generalized Anxiety Disorder 7-item (GAD-7) scale.
Results. The mean total score obtained on the VoiSS was 17.57, which is almost two points higher than the prot-
ocol’s passing score (16). The choristers who scored higher or equal to 16 points (51.5%, n = 271)—considered at vocal
risk—and the group who scored less than 16 points (48.5%, n = 255)—healthy group—were analyzed separately. The
risk group presented a mean total score of 26.34 on the VoiSS and 20.97 on the MSHI, with higher deviation on the
impairment subscale, followed by the disability and handicap subscales, along with mild anxiety. The healthy group
presented a mean total score of 8.27 on the VoiSS and 6.11 on the MSHI, also with higher deviation in the impairment
subscale, followed by disability and handicap, and a minimum level of anxiety.
Conclusion. Even in leisure activities, vocal care is necessary for the correct use of the singing voice, which demands
individual adaptations. The use of protocols for voice symptoms and singing handicap has revealed the possibility of
amateur choristers to present vocal risk.
Key Words: voice–dysphonia–singing–quality of life–self-assessment.

INTRODUCTION
There are many amateur choirs that are affiliated to schools, re-
ligious groups, communities, or other organizations that develop
this activity for self-gratification.1 The choir singing practice is
used as a tool for motivation and social integration,2 contribut-
ing for personal development, increasing self-esteem, and
preserving emotional balance.3 Some authors4 have mentioned
that this activity therapeutically relieves tension and sadness of
daily life. They also report the importance of music for the
elderly.5
Developing a healthy vocal singing technique in the choir is
essential for singing.1 Vocal misuse and abuse may cause some
voice disorders.6 In amateur choirs, the singers are not techni-
cally trained musicians; thus, they do not have the necessary skills
to consistently and reliably produce the sounds requested by the
conductors while avoiding vocal injuries.1 In these choirs, the
conductor is usually the only member with musical training. Many
choristers make rehearsals their only source of knowledge on
vocal techniques.1
The socialization provided by singing in a choir has broad-
ened the objectives of learning how to sing to a point where today
there are actually more lay than professional choirs. This brings
the layperson closer to musical achievement, but on the other
hand one should take vocal care into consideration in order to
avoid risks.7 Risk may be defined as the likelihood of a disease
Accepted for publication March 2, 2016.
Presentations in Congress: The Voice Foundation’s 44th Annual Symposium: Care of
the Professional Voice, Philadelphia, Pennsylvania, United States, 2015; the 14th Foun-
dation Otorhinolaryngology Congress, São Paulo, Brazil, 2015; and the 23rd Brazilian Speech-
Language Pathology and Audiology Congress, Salvador, Bahia, Brazil, 2015.
From the Speech-Language Pathology and Audiology Department, Universidade Federal
de São Paulo—UNIFESP, São Paulo, Brazil.
Address correspondence and reprint requests to Milka Rosa, Rua 15 de Novembro 1356,
Jundiaí, SP, 13201-305, Brazil. E-mail: milkabrosa@gmail.com
Journal of Voice, Vol. ■■, No. ■■, pp. ■■-■■
0892-1997
© 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jvoice.2016.03.002
in a population or group for a period of time, that is, the pos-
sibility of acquiring a voice disorder, in our case related to singing
activities and/or other situations of vocal use.8
Teachers and singers are professionals who present higher fre-
quency of voice disorders than the general population,9 and
functional dysphonia is the most frequent diagnosis10 among voice
professionals. It is even less frequent among amateur choris-
ters, who sing in choirs as a hobby. These choristers are rarely
submitted to vocal screening. They may not receive education
on proper voice use for speaking or for singing.11 Because of a
lack of specific preparation, amateur choristers may present symp-
toms that may lead to a vocal handicap. Less experienced singers
may be at a greater risk than professional singers.12 In other words,
the greater the singer’s experience, the lower the potential of a
vocal handicap.13
In a Swedish14 and an American15 study, the subjects with higher
vocal risk are singers, followed by consultants, teachers, lawyers,
pastors, telemarketing operators, salesmen, and health profes-
sionals. Singers present high prevalence of abnormal findings
on videolaryngostroboscopy examinations, ranging from reflux
to lesions caused by vocal abuse and tension on the vocal folds.16
It is known that voice professionals have higher occurrence of
vocal problems.15 When it comes to amateurs, the mean number
of problems reported in this population can be considerably high,17
and may be related to the lack of orientation regarding vocal well-
being or lack of singing-specific vocal techniques.
It is also known that, usually, not even voice professionals,
who depend on specific vocal training18 oriented to their needs,
undergo vocal screening. Speech language may contribute to the
early identification of vocal problems, preventing phonotrauma
and ensuring good vocal function for a better professional
performance.19 They may present symptoms related to vocal
health,7 such as throat clearing, secretion, hoarseness and dry
cough,20 or even neck pain or sore throat after long conversa-
tions, along with hoarseness or aphonia.21 On the other hand,
there are other aspects related to vocal behavior that can have
 ARTICLE IN PRESS
2 Journal of Voice, Vol. ■■, No. ■■, 2016
an influence on vocal risk, such as technical difficulties, lack of
knowledge on voice production, wrong vocal classification, in-
correct use of voice, and lack of vocal training on warm-up and
cool-down techniques.22,23
The symptoms might lead to a handicap on their choir ac-
tivities, which are more easily observed in less experienced singers
than professional singers.12 In other words, the longer the sin-
ger’s experience, the lower is his or her vocal handicap.13 Modern
singers with vocal complaints present higher self-reported hand-
icap compared with individuals without vocal complaints and
with subjects who do not sing.24 Similarly, for church amateur
singers, the handicap is higher in individuals with voice altera-
tions, and similar between men and women, regardless of age,
voice type, and associated use of professional speaking voice.25
Other studies have reported that women present more voice dis-
orders than men, and that the most frequent complaints are related
to the lack of vocal technique.17 The vocal self-image or self-
assessment is also directly related to the vocal experience level,
being most commonly positive in experienced singers and neg-
ative in less experienced singers.26
The presence of three or more vocal symptoms27 should be
seen as indicative of a possible voice disorder, presenting a vocal
handicap in their choir activities, possibly evolving into dys-
phonia and affecting their quality of life.28 However, these
symptoms may be linked to emotional factors, such as mood dis-
orders associated with concerns and constant stress regarding
their vocal health29 and degree of trait anxiety.30
If, on one hand, choir singing has positive influences on cho-
risters’ emotional state, providing relaxation and well-being,31
on the other hand anxiety may hinder their performance.32 Some
factors tend to increase anxiety, such as difficulty with music,
physical health, and characteristics and behavior of the conduc-
tor, among others.32 Studies with amateur singers have shown
that anxiety is common among children and young choristers,
suggesting that anxiety could occasionally distract them from
or interfere with their performance.32 Researchers interested in
investigating anxiety in musicians have been usually studying
professional singers; relatively few studies have focused on the
experience of amateur choirs.
The following were the aims of this study:
(1) to investigate the existence of vocal risk in amateur
singers; and
(2) to map the vocal risk and analyze the contribution of
general voice signs and symptoms, specific singing hand-
icap, and generalized anxiety.
METHODS
A cross-sectional questionnaire study was carried out after ap-
proval was given by the Research Ethics Committee of the
Universidade Federal de São Paulo (CEP-UNIFESP n° 842.117).
The participants who were selected signed a free and informed
consent form. The invitation for participation in the study was
carried out through amateur choir conductors by phone or in person.
Initially, 38 amateur choirs from the city of São Paulo, Brazil,
were invited, which was equivalent to 926 choristers. The con-
ductors were provided with information about the purpose, design,
content, and length of the study. After this initial contact, the
researcher scheduled an appointment with each choir conduc-
tor on when to answer the questionnaires. Because of problems
in schedules, only 35 choirs were included in the study. The initial
data included 786 questionnaires filled in by choristers.
The data collection procedure included answering the per-
sonal identification and characterization form, the Voice Symptom
Scale (VoiSS),33 the Modern Singing Handicap Index (MSHI),24
and the Generalized Anxiety Disorder 7-item (GAD-7) scale.34
The choristers answered the questionnaires at their residences
or at the choir rehearsal site after the researcher provided a verbal
explanation about the aims of the study. The questionnaires were
then returned to the conductor, and then to the researcher. The
data were collected between September 2013 and January 2014.
Subjects were selected using the following criteria: older than
18 years, to be a member of the choir for over 6 months, and
to correctly fill in all of the questionnaires. These data were ob-
tained from each questionnaire. Subjects who were excluded were
those who presented with hearing impairments, as well as neu-
rologic, psychiatric, or psychological conditions, which could
prevent them from appropriately answering the questionnaires.
The data regarding the inclusion and exclusion criteria were ob-
tained from the answers of the participants.
After the inclusion and exclusion criteria were applied, the
final sample comprised 526 individuals from 35 choirs, 340
females and 186 males, with ages between 18 and 89 years (mean
age of 42.02 years). Figure 1 presents the flowchart of the cho-
risters included in the research.
The choirs selected for the study are maintained by univer-
sities, schools, churches, companies, hospitals, foundations,
institutions, or private funding. Their repertoire is eclectic, from
folkloric songs to sacred music, and playing a cappella or ac-
companied by a piano or other musical instruments.
Self-assessment questionnaires are convenient tools to screen
singers who might be at risk for vocal injury. The question-
naires are inexpensive and easy to administer. These protocols
are very subjective. They characterize the impact of a disease
or disorder on an individual’s quality of life.35 They have been
developed as a means of quantifying the impact of dysphonia.
In addition, they have been proven useful in helping conduc-
tors map the vocal risk of amateur choral singers for the purpose
of referral to otorhinolaryngologists and speech language pa-
thologists. Even in leisure activities, vocal care is necessary to
prevent vocal alterations.
The identification form was composed of closed and open ques-
tions on four aspects: identification data, chorister’s profile, general
health, and vocal self-assessment (Table 1).
On the term “profession,” participants were classified in seven
categories, according to the vocal demand and the style of voice
and speech expected for each profession. This classification was
based on the categorization adapted from Shewell.36 An extra
category (“others”) was developed by the authors to comprise
all the professions in the present study (Chart 1).
There are several self-assessment questionnaires translated into
and are validated for Brazilian Portuguese. In this study, par-
ticipants answered three questionnaires: the VoiSS,33,37 the MSHI,24
and the GAD-7 scale.34
 ARTICLE IN PRESS
Milka Rosa and Mara Behlau Mapping of Vocal Risk in Amateur Choir 3

38 choirs contacted
926 choristers

Phone contact or
in person

35 choirs 3 choirs
786 choristers 140 choristers

Accepted to participate in Could not participate in

the study the study due to schedule
problems

Distribution of the
questionnaires

721 65
questionnaires questionnaires
returned not returned

526 195
valid questionnaires
questionnaires excluded

- Older than 18 years 89 33 14 59

- In the choir for over 6 choristers choristers choristers choristers
months Did not fill the Under 18 years Diseases In the choir for
- Complete fulfillment of questionnaires entirely old under 6 months
the questionnaires

7 4 3
choristers choristers choristers
Hearing Neurological Psychiatric
impairments conditions conditions

FIGURE 1. Flowchart explaining questionnaire’s selection.

The VoiSS38 self-assessment questionnaire is a vocal symp-
toms scale used to reflect physical, communicational, and
emotional symptoms implicit in an adult’s dysphonia.35 VoiSS
is considered a rigorous and psychometrically robust protocol
for vocal self-assessment,39,40 providing information about func-
tionality, emotional impact, and physical symptoms of voice
problems, including their consequences for all aspects of life.
This protocol has been validated for Brazilian Portuguese as
Escala de Sintomas Vocais (ESV).33 This version presents 30 in-
terrogative questions, each one scored from 0 to 4, according
to the frequency of occurrence: never, rarely, sometimes, almost
always, and always, respectively. From these questions, 15 regard
the limitation domain (functionality), 8 the emotional domain
(psychological effect), and 7 the physical domain (organic symp-
toms), which produce partial scores. Both the total score and the
scores for each domain are calculated by the simple sum of points.
The maximum score for the limitation domain is 60 points, for
the emotional domain 32 points, and for the physical domain
28 points, and the maximum total score is 120 points. The passing
score is 16 points,33 which means that the higher the scores in
this protocol, the higher the perception of the general level of
voice alteration regarding impairment, emotional reactions, and
physical symptoms reported. Scores lower than 16 indicate vocally
healthy individuals.
VoiSS undoubtedly provides significant results, although it is
not specifically designed for the singing voice. To meet the needs
of this public, Italian phoniatrist Franco Fussi41 developed the
MSHI and the Classical Singing Handicap Index, which are
adapted from the American protocol Voice Handicap Index.42
The MSHI protocol, which contains specific aspects of modern
singing styles, has a translated and culturally adapted version
for Brazilian Portuguese.24 It is composed of 30 items, divided
 ARTICLE IN PRESS
4 Journal of Voice, Vol. ■■, No. ■■, 2016

into three subscales—disability, handicap, and impairment—

TABLE 1.
Sample Characterization (n = 526) According to Gender,
with functional, emotional, and organic domains, respectively.
Singers’ Profile Data Regarding the Use of Singing Voice, The answers are marked with a 5-point scale, according to the
General Health Data, and Vocal Self-Assessment frequency of occurrence: 0 = never, 1 = almost never, 2 = some-
times, 3 = almost always, and 4 = always. The higher the score,
Characterization n %
the greater the voice handicap observed by the individual singing.
Gender The GAD-7 scale34 is a valid and reliable self-assessment
Female 340 64.63
Male 186 35.36 screening questionnaire43 for anxiety signs and symptoms. The
Profession translation into Portuguese language was done by Pfizer (Copy-
Artistic 35 6.65 right © 2005 Pfizer Inc., New York, NY), and there is evidence
Informants 62 11.78
of its validity in Brazil.44 It has been proven to be a valid screen-
Leaders and sellers 37 7.03
Did not answer 16 3.04 ing tool to detect anxiety.45 The scale is composed of seven items,
Others 320 60.83 and each question receives a score from 0 to 3 according to the
Support 43 8.17 frequency of occurrence: not at all, several days, more than half
Transmitters 11 2.09
Voice of command 2 0.38
the days, and nearly every day. The scores are calculated by the
In how many choirs participates as singer? simple sum of points and vary from 0 to 21, evaluating the fre-
1 choir 380 72.24 quency of anxiety signs and symptoms in the last 2 weeks. The
2 choirs 106 20.15 scores are classified as minimum risk (0–4 points), mild risk (5–9
3 choirs 27 5.13
4 choirs or more 11 2.09
points), moderate risk (10–14 points), or severe risk (15–21
Did not answer 2 0.38 points); thus, the higher the score obtained, the more anxious
How many hours of practice per week? the individual considers himself or herself. Scores of 10 points
Up to 2 hours 245 46.57 or higher are considered positive indicator of anxiety signs and
2–4 hours 177 33.65
4–6 hours 59 11.21
symptoms. Statistical analysis adopted a significance level of 5%
More than 6 hours 40 7.60 (0.05).
Did not answer 5 0.95 The Tukey multiple comparison test was used to analyze the
For how long have participated in the choir? means for the pass and fail groups and for all the VoiSS ques-
6 months to 1 year 98 18.63
1–3 years 141 26.80 tions, as this test is used to test all the differences between the
More than 4 years 276 52.47 two means.
Did not answer 11 2.09 The equality of two proportions test is a nonparametric test
Use the voice in other activities?
that shows whether the proportion of answers of two deter-
Yes 169 32.12
No 342 65.01 mined variables or their levels is statistically significant. This
Did not answer 15 2.85 test was used to compare the pass and fail groups on the dis-
Perform vocal warm up? tribution of the variables profession and levels of anxiety, which
Yes 502 95.43
No 23 4.37
are qualitative, as well as to compare between genders regard-
Did not answer 1 0.19 ing the distribution of the variables pass and fail and levels of
Perform vocal cool down? anxiety.
Yes 64 12.16 Analysis of variance is a parametric test frequently used to
No 425 80.79
Did not answer 37 7.03
compare the means through variance. This test was used to analyze
Have had voice problems? the MSHI scores by comparing the means of the pass and fail
Yes 100 19.01 groups, as well as to compare the genders and the pass and fail
No 421 80.03 groups on their performances in all the questionnaires used in
Did not answer 5 0.95
Have ever had voice treatment?
this study.
Yes 46 8.74 The total sample was divided into pass and fail, according to
No 374 71.10 the results obtained from the VoiSS screening, which is consid-
Did not answer 106 20.15 ered an appropriate tool to classify the presence of voice
Have consulted an ENT specialist?
Yes 94 17.87 deviations.33
No 420 79.84
Did not answer 12 2.28 RESULTS
Have consulted a speech language pathologist?
The mean total score on the VoiSS protocol for the sample was
Yes 52 9.88
No 463 88.02 17.57, which is almost two points higher than the passing score
Did not answer 11 2.09 of the instrument (16). The sample was divided into pass and
Vocal self-assessment fail based on this score. The pass group included 255 subjects
Excellent 19 3.61
Very good 85 16.15
(48.5% of the sample) with scores lower than 16 points, and the
Good 312 59.31 fail group included 271 subjects (51.5%) with scores of 16 points
Fair 102 19.39 or higher (Table 2).
Bad 6 1.14 Pass and fail responses were analyzed according to the pro-
Did not answer 2 0.38
fession and the anxiety degree of the subjects (Table 3).
 ARTICLE IN PRESS
Milka Rosa and Mara Behlau Mapping of Vocal Risk in Amateur Choir 5

Categories Vocal demand Professionals

Long periods using the voice with Psychologists, architects,

frequent moments of silence; reduced administrators, analysts, engineers,
Support
intensity, sometimes dealing with high nurses, pharmacists, doctors, and
levels of stress. computer technicians.

Short periods using the voice with high
intensity and presence of background
Voice of command
noise. Weather or smoking may be
damaging factors.
Army sergeants, cops, players, barmen,
traders of the stock change,
auctioneers, pastors, postmen, and
outdoor workers.

Long periods using the voice with Receptionists and telemarketers.

microphone and earphone. High levels
of stress with possible aggressiveness
Transmitters towards the listener, and little body
movement.

Uninterrupted periods of speech, Speech-language pathologists,

varying the number of listeners and the lecturers, teachers, and people working
size of the space. High levels of in advertising.
Informants responsibility with the group of listeners,
using the voice to inform, persuade,
inspire, etc.

Usually short uninterrupted periods Attorneys, politicians, sellers,

speaking (less than the informants) at managers, and business men and
high intensity, but with high relevance to women.
Leaders/Sellers the use of voice in order to influence
people.

Long periods of high vocal energy, high Singers, actors, broadcasters, and
level of ability to play a role and journalists.
emotionally convince. Body movement
Artistic variation is necessary. Usually has
vocal training.

Short periods of voice use without great Retired men and women, students,
vocal demand. housewives, cooks.
Others

CHART 1. Categorization of voice professionals according to the use of voice (adapted from Shewel, 2009).

The subjects who failed the screening were mostly from the
professional category “informants,” which includes teachers, lec- TABLE 2.
turers, speech language pathologists, and advertising people34 Mean Total Score on the VoiSS Protocol, According to
(Chart 1). the Passing Score (16)
Regarding anxiety, there were significant differences between VoiSS Protocol
the pass and fail groups for subjects with minimal, mild, and
Mean
moderate anxiety degrees. Screening n % Total Score
On the MSHI, statistically significant mean differences were
found between the groups in all subscales. The subjects who failed Pass 255 48.5 8.27
Fail 271 51.5 26.34
the screening obtained the higher means on the subscales im-
Total 526 100 17.57
pairment (10.53), disability (6.56), and handicap (3.87) (Table 4).
 ARTICLE IN PRESS
6 Journal of Voice, Vol. ■■, No. ■■, 2016

TABLE 3.
Numeric and Percentage Distribution of the Choir Singers Regarding Their Profession and Anxiety Degree, According to
the Screening Results on the VoiSS Protocol
VoiSS Screening
Pass Fail
Profession and GAD-7 n % n % P value
Profession
Artistic 15 5.9 20 7.4 0.491
Informants 19 7.5 43 15.9 0.003*
Leaders and sellers 23 9.0 14 5.2 0.084†
Did not answer 8 3.1 8 3.0 0.902
Others 156 61.2 164 60.5 0.877
Support 25 9.8 18 6.6 0.186
Transmitters 8 3.1 3 1.1 0.104
Voice of command 1 0.4 1 0.4 0.966
Anxiety degree (GAD-7)
Minimal 161 63.1 87 32.1 <0.001*
Mild 86 33.7 139 51.3 <0.001*
Moderate 7 2.7 41 15.1 <0.001*
Intense 1 0.4 4 1.5 0.200
Note: Two-sample test for equality of proportions.
* Significant value (P ≤ 0.05).
†
Values tending toward significance.
Abbreviations: GAD-7, Generalized Anxiety Disorder 7; VoiSS, Voice Symptom Scale.

When the genders were compared on the VoiSS screening,
it was observed that women failed more than men. They also
present higher anxiety levels (Table 5).
On the other hand, the performances were very similar between
men and women on the MSHI protocol, considering the VoiSS
screening results. There was a significant difference between
genders only in the disability subscale for the subjects who
passed the screening, and a tendency toward significance
in the impairment subscale for the ones who failed it
(Table 6).

TABLE 4.
Distribution of Choir Singers According to the Results on the MSHI Subscales, Considering the Screening Results on the
VoiSS
MSHI and VoiSS
Screening n Mean Median Standard Deviation CV (%) Min Max CI P value
Disability
VoiSS screening
Pass 255 1.85 1 2.87 155 0 20 0.35 <0.001*
Fail 271 6.56 5 5.78 88 0 31 0.69
Handicap
VoiSS screening
Pass 255 0.94 0 1.88 200 0 16 0.23 <0.001*
Fail 271 3.87 2 4.70 121 0 22 0.56
Impairment
VoiSS screening
Pass 255 3.33 2 3.98 120 0 24 0.49 <0.001*
Fail 271 10.53 10 7.18 68 0 34 0.86
Total
VoiSS screening
Pass 255 6.11 4 7.31 120 0 42 0.90 <0.001*
Fail 271 20.97 18 15.39 73 0 87 1.83
Note: Analysis of variance test.
* Significant values (P ≤ 0.05).
Abbreviations: CI, confidence interval; CV, coefficient of variation; Max, maximum score; Min, minimum score; MSHI, Modern Singing Handicap Index; VoiSS,
Voice Symptom Scale.
 ARTICLE IN PRESS
Milka Rosa and Mara Behlau Mapping of Vocal Risk in Amateur Choir 7

and fail) were related to the subjects’ professions and anxiety

TABLE 5.
Distribution of Choir Singers by Gender, According to the
levels (Table 3). The survey confirmed that subjects in the cat-
Results on the VoiSS and GAD-7 egory “informants,”36 which includes teachers, lecturers, and
others, revealed a significant prevalence of fail results (P = 0.03).
VoiSS Screening Female Male Consequently, the impact of voice changes may interfere with
and GAD-7 n % n % P value the amateur singer’s voice in other areas of life that are unre-
VoiSS screening lated to musical activities10,46 (Table 3). This overlap of activities
Pass 153 45.0 102 54.8 0.031* increases their voice demand, which may increase the risk of
Fail 187 55.0 84 45.2 vocal alterations. A vocal alteration for a singer can be even
VoiSS screening greater, as this might interfere with his or her professional life.47
and GAD-7 Amateur singers present an intense vocal demand when the hours
Pass of professional use and singing voice use are considered together.48
Minimal 88 57.5 73 71.6 0.023* It is known that vocal care is recommended even when singing
Mild 60 39.2 26 25.5 0.023* is considered an amateur activity, as the amateurism in this mo-
Moderate 5 3.3 2 2.0 0.531
dality, with no specific orientation, can lead to voice alterations.49
Intense 0 0.0 1 1.0 0.220
Fail
Vocal overload50 may increase the risk, and the sum of vocal
Minimal 54 28.9 33 39.3 0.090† abuses may lead singers to a higher risk of presenting with vocal
Mild 97 51.9 42 50.0 0.776 symptoms.10
Moderate 33 17.6 8 9.5 0.084† Anxiety and stress cause physiological changes in the body,
Intense 3 1.6 1 1.2 0.794 and consequently the structures that compose the vocal tract are
Note: Two-sample test for equality of proportions. also affected, which results to modifications in vocal emission.51
* Significant values (P ≤ 0.05). In this study, the GAD scale34 was used to measure the state of
†
Values tending toward significance. anxiety. In general, the anxiety levels were low, prevailing in
Abbreviations: GAD-7, Generalized Anxiety Disorder 7; VoiSS, Voice
Symptom Scale. minimal and mild degrees, which indicates that amateur choir
singing does not contribute to increasing anxiety (Table 3). Many
professional singers mention mood disorders and stress related
All the questionnaires used in this study were to their vocal health, probably due to expectations regarding the
compared—VoiSS (screening), MSHI, and GAD-7—and sta- future of their careers. Hence, emotional factors are apparently
tistically significant differences were found in all groups. The different for amateur singers, who do not suffer this pressure with
highest total mean was obtained in the VoiSS screening (17.57), their singing.29 The choristers in the present study were from the
for the subjects who failed (26.34). The lowest means were for region of São Paulo, a city that, due to its complexity, may present
the subjects who passed the VoiSS screening (8.27) and the ones a higher probability for the individuals to develop psychologi-
who passed the MSHI (6.11). No traces of anxiety were found cal problems and behavioral disorders.52 However, choir singing
among amateur choristers, as the total means, for both groups, is seen as a leisure activity, contributing to the reduction of stress
were below the passing score for the GAD-7 (10), as shown in among participants. Our results confirm previous findings that
Table 7. showed that amateur group singing produces positive emotions,
The mean values for each question of the VoiSS protocol were influencing the emotional state as well as the immunologic func-
compared according to the results on the screening (pass or fail). tions in human beings. Thus, musical behavior possibly has a
The three higher means were for Q7—coughing or throat clear- positive influence on general well-being and health.31
ing (1.33), Q16—difficulty speaking in noisy environments (1.21), The MSHI protocol is recommended to verify the impact of
and Q1—difficulty being heard by others (1.17) (Table 8). a voice alteration in singers. The MSHI protocol and its subscales
were analyzed according to the VoiSS screening results, showing
DISCUSSION significant differences between the pass and fail groups. The highest
This study initially investigated the existence of vocal risk in mean was observed among the subjects who failed the screen-
amateur choral singers using the VoiSS, which is a self- ing in the impairment subscale, followed by the disability and
assessment screening instrument that presents the perfect the handicap subscales (Table 4). Because the participants are
classification.33 The results for the total sample showed the mean amateur singers and singing is not their primary source of income,
value above the passing score (16), suggesting possible vocal the results did not show great handicap, and the emotional subscale
risk in the studied population (Table 2). Then, the participants presented the lowest mean in this protocol.17,53,54 Choristers are
were grouped according to their screening results—pass (48.5%) aware when there is something wrong with their voice, and they
and fail (51.5%)—with the aim to further study the population are able to indicate their limitation in the self-assessment.
at risk for voice problems. Such classification was idealized to The analysis of gender distribution on the VoiSS screening
facilitate the understanding of the relationship between voice (Table 5) showed that women presented greater potential for voice
symptoms and vocal risk, and its overall impact on the quality problems, as 55% of them were classified as fail, whereas 45.2%
of life of choir singers. of the men composed this group. In previous studies, women
Thus, using the equality of two proportions test in the statis- not only had a higher lifetime prevalence of voice disorders
tical analysis, it was observed that the screening results (pass (46.3% vs 36.9%), but also had a higher prevalence of chronic
 ARTICLE IN PRESS
8 Journal of Voice, Vol. ■■, No. ■■, 2016

TABLE 6.
Distribution of Choir Singers by Gender, According to the MSHI Subscales, Considering the Screening Results on the
VoiSS
VoiSS Screening and MSHI n Mean Median Standard Deviation CV (%) Min Max CI P value
Disability
VoiSS screening
Pass
Female 153 1.43 1.0 2.12 148 0 10 0.34 0.017*
Male 102 2.48 1.0 3.64 147 0 20 0.71
Fail
Female 187 6.66 6.0 5.96 90 0 31 0.85 0.693
Male 84 6.36 5.0 5.37 84 0 23 1.15
Handicap
VoiSS screening
Pass
Female 153 0.82 0.0 1.43 175 0 7 0.23 0.239
Male 102 1.12 0.0 2.39 214 0 16 0.46
Fail
Female 187 4.11 2.0 5.04 123 0 22 0.72 0.225
Male 84 3.36 2.0 3.84 114 0 17 0.82
Impairment
VoiSS screening
Pass
Female 153 3.14 2.0 3.39 108 0 17 0.54 0.690
Male 102 3.60 2.0 4.74 132 0 24 0.92
Fail
Female 187 11.04 10.0 7.52 68 0 34 1.08 0.078†
Male 84 9.38 8.0 6.26 67 0 26 1.34
Total
VoiSS screening
Pass
Female 153 5.39 4.0 5.70 106 0 31 0.90 0.154
Male 102 7.20 4.0 9.13 127 0 42 1.77
Fail
Female 187 21.81 18.0 16.32 75 0 87 2.34 0.180
Male 84 19.10 16.0 12.98 68 0 55 2.78
Note: Analysis of variance test.
* Significant values (P ≤ 0.05).
†
Values tending toward significance.
Abbreviations: CI, confidence interval; CV, coefficient of variation; Max, maximum score; Min, minimum score; MSHI, Modern Singing Handicap Index; VoiSS,
Voice Symptom Scale.

voice disorders than man.55 This may be due to the fact that there
are more women than men in professions who predispose them-
selves to present with voice complaints; these include professions
related to educational activities, as teachers have a higher rate
of self-reported voice disorders than those in other occupa-
tions. Furthermore, women not only reported higher rates of voice
disorders; in general, they also reported more chronic voice
disorders.55 It has been hypothesized that women are more vul-
nerable to voice disorders because of structural differences in
their laryngeal anatomy, as women have shorter vocal folds and
produce voice at a higher fundamental frequency.55 Previous
studies have identified differences between male and female teach-
ers in the report of voice problems. It has been shown that women
were significantly more likely to report voice problems associ-
ated with teaching.55,56 Hence, women are more likely to present
vocal disorders57,58 and, with minimal difference, women are more
anxious in the GAD-7 scale than men.17,58 Unlike professional
singers whose livelihood depends on vocal well-being,
amateur singers may not recognize the significance of a vocal
handicap.
The literature reveals that, in general, performing musicians
as a group are more anxious than nonmusicians. Female singers
have been shown as significantly more highly trait anxious than
the female non-singer population. However, it cannot be con-
cluded that female singers are more highly trait anxious than male
singers.59
In a previous study developed with music college singing stu-
dents, no difference was found between male and female subjects
regarding musical performance anxiety.59
On the other hand, men and women presented very similar
outcomes on the MSHI protocol when the VoiSS screening results
were considered (Table 6).
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Milka Rosa and Mara Behlau Mapping of Vocal Risk in Amateur Choir 9

TABLE 7.
Distribution of Choir Singers According to the Results on the Instruments Used in the Study
Instrument n Mean Median Standard Deviation CV (%) Min Max CI P value
VoiSS
VoiSS screening
Pass 255 8.27 9 4.26 52 0 15 0.52
Fail 271 26.34 24 9.27 35 16 68 1.10 <0.001*
Total 526 17.57 16 11.61 66 0 68 0.99
MSHI
VoiSS screening
Pass 255 6.11 4 7.31 120 0 42 0.90
Fail 271 20.97 18 15.39 73 0 87 1.83 <0.001*
Total 526 13.77 9 14.24 103 0 87 1.22
GAD-7
VoiSS screening
Pass 255 3.91 4 2.80 72 0 16 0.34
Fail 271 6.24 6 3.43 55 0 18 0.41 <0.001*
Total 526 5.11 5 3.34 65 0 18 0.29
Note: Analysis of variance test.
* Significant value (P ≤ 0.05).
Abbreviations: CI, confidence interval; CV, coefficient of variation; GAD-7, Generalized Anxiety Disorder 7; Max, maximum score; Min, minimum score; MSHI,
Modern Singing Handicap Index; VoiSS, Voice Symptom Scale.

When all the protocols used in this study were compared
(VoiSS, MSHI, and GAD-7), as shown in Table 7, it was ob-
served that the VoiSS screening presented a total mean of four
points higher than the mean observed when the performance on
the MSHI protocol was selected. The results agree with the lit-
erature for the subjects who presented scores close to 20 on the
MSHI, as church amateur singers have presented a total mean
of 23 points on this instrument.25
Another study24 showed that amateur singers with com-
plaints presented 26.91 points and those with no complaints 16.91
points using the MSHI.24 In the GAD-7 scale, both groups were
below the passing score (≥10 points). This suggests an absence
of high anxiety traits in amateur choristers, although they live
in a stressful city. Because singing is a leisure activity, not a pro-
fessional one, the degrees of anxiety among this subject group
were minimal to mild.52 Thus, these protocols can assist speech
language pathologists and choir conductors in the selection
procedures.
The mean values for each question of the VoiSS protocol were
compared according to the results on the screening (pass or fail).
The higher means were found for the questions “Do you cough
or clear the throat?” (1.33), “Do you have difficulties speaking
in noisy environments?” (1.21), “Do you have problems calling
people’s attention?” (1.17), and “Do you have problems singing?”
(1.10). It was found that all the means presented values close
to one point, which corresponds to an answer between “rarely”
and “sometimes” (Table 8). Therefore, this score does not rep-
resent great vocal risk. Although this population sings as an
avocation, the impact of singing on the voice can have impli-
cations for its use in the workplace. Amateur choristers who
present with voice complaints or symptoms should seek assess-
ment from a medical professional. Greater understanding of
appropriate voice use could enhance the amateur’s choral singing
experiences. A qualified speech language pathologist could be
an invaluable asset to an amateur choral singing group by pro-
viding training in vocal hygiene and effective voice use.60
CONCLUSIONS
Even in a population that develops vocal activity for pleasure
or leisure, it is important to know the profile of the amateur cho-
risters in order to understand more broadly the risks and factors
that might diminish vocal health.
Based on the analyses performed in this study with amateur
singers, it may be concluded that there is vocal risk in this
population, higher for female singers and those with profes-
sions classified as “informants” (speech language pathologists,
lecturers, teachers, and people working in advertising). The anxiety
levels of the choristers were low, indicating that the activity is
not anxiogenic and may actually contribute to reducing stress
common to those who live in big cities.
There are vocal symptoms that place this population at po-
tential risk, and they are related to the higher handicap observed
in singing.
The combined use of two protocols identified a higher number
of choristers with potential problems than the use of these pro-
tocols separately.
Because amateur choristers appear to be at higher risk for voice
injury, an educational initiative on vocal health and well-being
seems warranted. The evaluation instruments used in this study
would appear to be of benefit for speech language pathologists
and choral conductors. The results of the screening process may
indicate the need for referral to a medical professional for further
assessment and training.
 ARTICLE IN PRESS
10 Journal of Voice, Vol. ■■, No. ■■, 2016

TABLE 8.
Mean Values on the VoiSS Questions
Screening
Questions of VoiSS Pass Fail Mean Total P value
1. Do you have problems calling people’s attention? 0.80 1.52 1.17 0,199
2. Do you have problems singing? 0.71 1.47 1.10 0.001
3. Does your throat hurt? 0.48 1.27 0.88 <0.001*
4. Is your voice hoarse? 0.30 1.02 0.67 <0.001*
5. When you talk with a group of people, do they have difficulties hearing you? 0.24 1.00 0.62 <0.001*
6. Do you lose your voice? 0.27 0.97 0.63 <0.001*
7. Do you cough or clear the throat? 0.92 1.73 1.33 Ref.
8. Is your voice weak/low? 0.37 1.30 0.85 <0.001*
9. Do you have problems speaking on the phone? 0.08 0.42 0.25 <0.001*
10. Do you feel bad or depressed due to your voice problem? 0.03 0.58 0.31 <0.001*
11. Do you feel something stuck in your throat? 0.28 1.04 0.67 <0.001*
12. Do you have swollen nodules in your neck? 0.03 0.30 0.16 <0.001*
13. Do you feel embarrassed due to your voice problem? 0 0.40 0.21 <0.001*
14. Do you get tired talking? 0.15 0.91 0.54 <0.001*
15. Does your voice problem make you stressed or nervous? 0.04 0.49 0.27 <0.001*
16. Do you have difficulties speaking in noisy environments? 0.64 1.75 1.20 0.714
17. Is it difficult to talk strong (high) or to yell? 0.39 1.38 0.89 <0.001*
18. Does your voice problem bother your family or friends? 0.03 0.31 0.17 <0.001*
19. Do you have a lot of secretion or phlegm in your throat? 0.49 1.37 0.94 <0.001*
20. Does the sound of your voice change during the day? 0.32 1.16 0.74 <0.001*
21. Do people seem to get irritated with your voice? 0.07 0.45 0.26 <0.001*
22. Do you have stuffy nose? 0.62 1.32 0.97 <0.001*
23. Do people ask you what is wrong with your voice? 0.02 0.22 0.12 <0.001*
24. Does your voice seem hoarse and dry? 0.08 0.73 0.41 <0.001*
25. Do you have to make an effort to speak? 0.06 0.69 0.38 <0.001*
26. How often do you have throat infections? 0.66 1.22 0.94 <0.001*
27. Does your voice fail in the middle of a sentence? 0.16 0.83 0.50 <0.001*
28. Does your voice make you feel incompetent? 0.03 0.36 0.19 <0.001*
29. Are you ashamed of your voice problem? 0.01 0.23 0.12 <0.001*
30. Do you feel lonely because of your voice problem? 0.02 0.14 0.08 <0.001*
Total score 8.27 26.34 17.57
Note: Tukey test.
* Significant value (P ≤ 0.05).
Abbreviation: VoiSS, Voice Symptoms Scale.

Acknowledgment 7. Braun-Janzen C, Zeine L. Singers’ interest and knowledge level of vocal

The authors are indebted to Conselho Nacional de
Desenvolvimento Científico e Tecnológico—CNPq for funding
this research.
REFERENCES
1. Smith B, Sataloff RT. Choral Pedagogy. 2nd ed. San Diego: Plural; 2006.
2. Kirsh ER, van Leer E, Phero HJ, et al. Factors associated with singers’
perceptions of choral singing well-being. J Voice. 2013;27:786.e25–786.e32.
3. Clift SM, Hancox G, Morrison I, et al. Choral singing and psychological
wellbeing: quantitative and qualitative findings from English choirs in a
cross-national survey. J Appl Arts Health. 2010;1:19–34.
4. Costa CRBSF, Santos MM, Franco KS, et al. Music and transformation in
the social and educative confinement measure. Rev Psicologia:Ciência e
Profissão. 2011;31:840–855.
5. Johnson JK, Louhivuori J, Stewart AL, et al. Quality of life (QOL) of older
adult community choral singers in Finland. Int Psychogeriatr. 2013;25:1–10.
6. Achey MA, He MZ, Akst LM. Vocal hygiene habits and vocal
handicap among conservatory students of classical singing. J Voice.
2016 Mar;30:192–197. 10.1016/j.jvoice.2015.02.003. Epub 2015
Mar 19.
function and dysfunction: survey findings. J Voice. 2009;23:470–483.
8. Santos JN, Rodrigues ALV, Silva AFG, et al. Percepção de agentes
comunitários de saúde sobre os riscos à saúde fonoaudiológica. Rev Soc
Bras Fonoaudiol. 2012;17:333–339.
9. Verdolini K, Ramig LO. Review: occupational risks for a voice problem.
Log Phon Vocol. 2001;26:37–46.
10. Van Houtte E, Van Liede K, D’Haeseleer E, et al. The prevalence of laryngeal
pathology in a treatment-seeking population with dysphonia. Laryngoscope.
2010;120:306–312.
11. Soares EB, Brito CMCP. Hábitos e perfil vocal em coralistas. Acta ORL.
2009;27:28–35.
12. Cohen SM, Jacobson BH, Garrett CG, et al. Creation and validation of the
Singing Voice Handicap Index. Ann Otol Rhinol Laryngol. 2007;117:402–
406.
13. Paoliello K, Oliveira G, Behlau M. Desvantagem vocal no canto mapeado
por diferentes protocolos de autoavaliação. Codas. 2013;25:463–468.
14. Fritzell B. Voice disorders and occupations. Log Phon Vocol. 1996;21:7–
12.
15. Titze IR, Lemke J, Montequin D. Populations in the US work force who
rely on voice as a primary tool of trade. A preliminary report. J Voice.
1997;11:254.
 ARTICLE IN PRESS
Milka Rosa and Mara Behlau Mapping of Vocal Risk in Amateur Choir
16. Myint C, Moore JE, Hu A, et al. A comparison of initial and subsequent
follow-up strobovideolaryngoscopic examinations in singers. J Voice. 2015.
Jul 21. pii: S0892-1997(15)00145-9. doi: 10.1016/j.jvoice.2015.06.013. [Epub
ahead of print].
17. Ribeiro VV, Santos AB, Bonki E, et al. Identificação de problemas vocais
enfrentados por cantores de igreja. Rev CEFAC. 2012;14:90–96.
18. Timmermans B, De Bodt MS, Wuyts FL, et al. Analysis and evaluation of
a voice-training program in future professional voice users. J Voice.
2005;19:202–210.
19. Gilman M, Merati A, Klein A, et al. Performer’s attitudes toward seeking
health care for voice issues: understanding the barriers. J Voice.
2012;23:225–228.
20. Ferreira LP, Gonçalves TAC, Loiola CM, et al. Associação entre os sintomas
vocais e suas causas referidas em um grupo de coristas da cidade de São
Paulo. Rev Distúrb Comum. 2010;22:47–60.
21. Oliveira IB. Avaliação fonoaudiológica da voz: reflexões sobre conduta, com
enfoque à voz profissional. In: Ferreira LP, Befi-Lopes DM, Limongi SCD,
eds. Tratado de Fonoaudiologia. São Paulo: Roca; 2004:11–24.
22. Gish A, Kunduk M, Sims L, et al. Vocal warm-up practices and perceptions
in vocalists: a pilot survey. J Voice. 2012;26:e1–e10.
23. Carmo SCW, Amorim GO, Andrade WTL. Saúde da voz de coralistas sem
orientação vocal. Rev Bras Ciências da Saúde. 2012;16:167–176.
24. Moreti F, Rocha C, Borrego MCM, et al. Desvantagem vocal no canto:
análise do protocolo Índice de Desvantagem para o Canto Moderno—IDCM.
Rev Soc Bras Fonoaudiol. 2011;16:146–151.
25. Prestes T, Pereira EC, Bail DI, et al. Desvantagem vocal em cantores de
igreja. Rev CEFAC. 2012;14:901–909.
26. Coelho ACC, Daroz IF, Silvério KCA, et al. Coralistas amadores:
autoimagem, dificuldades e sintomas na voz cantada. Rev CEFAC.
2013;15:436–443.
27. Donahue EN, Leborgne WD, Brehm SB, et al. Reported vocal habits of
first-year undergraduate musical theater majors in a preprofessional training
program: a 10-year retrospective study. J Voice. 2014;28:316–323.
28. Schwartz SR, Cohen SM, Dailey SH, et al. Clinical practice guideline:
hoarseness (dysphonia). Otolaryngol Head Neck Surg. 2009;141:S1–S31.
29. Keller A, Litzelman K, Wisk LE, et al. Does the perception that stress affects
health matter? The association with health and mortality. Health Psychol.
2012;31:677–684.
30. Almeida AAF, Behlau M, Leite JR. Correlação entre ansiedade e
performance comunicativa. Rev Soc Bras Fonoaudiol. 2011;16:384–389.
31. Kreutz G, Bongard S, Rohrmann S, et al. Effects of choir singing or listening
on secretory immunoglobulin A, cortisol, and emotional state. J Behav Med.
2004;27:623–635.
32. Ryan C, Andrews N. An investigation into the choral singer’s experience
of music performance anxiety. J Res Music Educ 2009;57:108–126.
33. Moreti F, Zambon F, Oliveira G, et al. Cross-cultural adaptation, validation,
and cutoff values of the Brazilian version of the Voice Symptom Scale-VoiSS.
J Voice. 2014;28:458–468.
34. Spitzer RL, Kroenke K, Williams JBW, et al. A brief measure for assessing
generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166:1092–
1097.
35. Silva FF, Moreti F, Oliveira G, et al. Efeitos da reabilitação fonoaudiológica
na desvantagem vocal de cantores populares profissionais. Audiol Commun
Res. 2014;19:194–201.
36. Shewell C. Voice Work: Art and Science in Changing Voices. New York:
Wiley-Blackwell; 2009:463–464.
37. Moreti F, Zambon F, Oliveira G, et al. Equivalência cultural da versão
brasileira da Voice Symptom Scale—VoiSS. J Soc Bras Fonoaudiol.
2011;23:398–400.
View publication stats
11
38. Deary IJ, Wilson JA, Carding PN, et al. VoiSS: a patient-derived, Voice
Symptom Scale. J Psychosom Res 2003;54:483–489.
39. Branski RC, Cukier-Blaj S, Pusic A, et al. Measuring quality of life in
dysphonic patients: a systematic review of content development in patient-
reported outcomes measures. J Voice. 2010;24:193–198.
40. Wilson JA, Webb A, Carding PN, et al. The Voice Symptom Scale (VoiSS)
and the Vocal Handicap Index (VHI): a comparison of structure and content.
Clin Otolaryngol Allied Sci. 2004;29:169–174.
41. Fussi F, Fuschini T. Foniatria artística: la presa in carico foniatrico-logopedica
Del cantante clássico e moderno. Audiol Foniatr. 2008;13:4–28.
42. Jacobson BH, Johnson A, Grywalski C, et al. The Voice Handicap Index
(VHI): development and validation. Am J Speech Lang Pathol. 1997;6:66–
70.
43. Kroenke K, Spitzer RL, Williams JBW, et al. Anxiety disorders in primary
care: prevalence, impairment, comorbidity, and detection. Ann Intern Med.
2007;146:317–325.
44. Mapi Research Institute. Certificate of Linguistic Validation Certificate:
General Anxiety Disorder-7 (GAD-7). Lyon, FR: Mapi Research Institute;
2006.
45. Lowe B, Decker O, Muller S, et al. Validation and standardization of the
Generalized Anxiety Disorder Screener (GAD-7) in the general population.
Med Care. 2008;46:266–274.
46. Zambon F, Moreti F, Behlau M. Coping strategies in teachers with vocal
complaint. J Voice. 2014;28:341–348.
47. Petrouci RT, Friedman S. Os sentidos da perda de voz. Rev Distúrb Comum.
2006;18:39–49.
48. Fuess VL, Lorenz MC. Disfonia em professores do ensino municipal:
prevalência e fatores de risco. Rev Bras Otorrinolaringol 2003;69:807–
812.
49. Dassie-Leite AP, Duprat AC, Busch R. Comparação de hábitos de bem-estar
vocal entre cantores líricos e populares. Rev CEFAC. 2011;13:123–131.
50. Villanueva-Reyes A. Voice disorders in the metropolitan area of San Juan,
Puerto Rico: profiles of occupational groups. J Voice. 2011;25:83–87.
51. Larrouy-Maestri P, Morsomme D. The effects of stress on singing voice
accuracy. J Voice. 2014;28:52–58.
52. Lederbogen F, Kirsch P, Haddad L, et al. City living and urban upbringing
affect neural social stress processing in humans. Nature. 2011;474:498–501.
53. Grape C, Sandgren M, Hansson LO, et al. Does singing promote well-being?:
An empirical study of professional and amateur singers during a singing
lesson. Integr Physiol Behav Sci. 2003;38:65–74.
54. Goulart BNG, Rocha JG, Chiari BM. Intervenção fonoaudiológica em grupo
a cantores populares: estudo prospectivo controlado. J Soc Bras Fonoaudiol.
2012;24:7–18.
55. Roy N, Merril RM, Thibeault S, et al. Prevalence of voice disorders in
teachers and the general population. J Speech Lang Hear Res. 2004;47:281–
293.
56. Smith E, Kirchner HL, Taylor M, et al. Voice problems among
teachers: differences by gender and teaching characteristics. J Voice.
1998;12:328–334.
57. Zimmer V, Cielo CA, Ferreira FM. Comportamento vocal de cantores
amadores. Rev CEFAC. 2012;14:298–307.
58. Brito AF, Ferreira LP, Souza LAP. Marcadores de estresse e sintomas vocais:
algumas relações possíveis. Rev Distúrb Comum. 2014;26:414–416.
59. Kokotsaki D, Davidson JW. Investigating musical performance anxiety
among music college singing students: a quantitative analysis. Music Educ
Res. 2010;5:45–59.
60. Barreto TMM, Amorim GO, Trindade EMF, et al. Perfil da saúde vocal de
cantores amadores de igreja evangélica. Rev Soc Bras Fonoaudiol.
2011;16:140–145.